5 Steps for Reducing Inappropriate Hospital Readmissions

It is an indisputable fact that inappropriate hospital readmissions are a drain on hospital resources, time and money. These readmissions result in billions of dollars being wasted. Each year, nearly 20 percent of Medicare beneficiaries are readmitted to hospitals within 30 days of discharge and account for $17.5 billion in additional costs for CMS.

To combat the additional costs, CMS established the Readmission Reduction Program. The program took effect in October 2012, and it aims to reduce readmissions by slashing reimbursements for hospitals that have a high number of preventable readmissions for specific conditions, such as heart failure, heart attack and pneumonia. Additional diseases and diagnoses will be added to the program in the years to come.

Up until Oct. 1, 2013, the penalty for hospitals with readmission rates in excess of the rate established by CMS was a maximum of 1 percent. After Oct. 1, it rose to 2 percent, and it will increase to 3 percent on Oct. 1, 2014.

Challenges to reducing readmission ratesOne of the biggest challenges to reducing inappropriate readmissions is flow of information and communication, says Jasen W. Gundersen, MD, president of Knoxville, Tenn.-based TeamHealth Hospital Medicine. "Keeping a concise and accurate flow of information is critical," he explains.

Unclear discharge instructions, and problematic discharge processes and medication reconciliation are also common causes of inappropriate readmissions. "Another challenge is re-engineering the discharge process so that it is really patient centered," says Paul Hildebrand, MD, associate director of the TeamHealth Patient Safety Organization.

Strategies for reducing readmission ratesLuckily, the challenges are not impossible to overcome. Inappropriate readmissions are preventable through process improvement and more effective coordination during and after a patient stay. Here are five steps hospitals can take to reduce inappropriate readmissions:

1. Recognizing high-risk patients. To effectively reduce readmissions, hospitals need to recognize high-risk patients as soon as they are admitted. "You need to recognize them up front, and then you need to work extensively with them and their families," says Dr. Gundersen.

There are eight characteristics of high-risk patients, according to the Society of Hospital Medicine: prior hospitalizations, problem medications, depression, certain principal diagnoses, use of multiple medications, poor health literacy, poor patient support and palliative care.Once the providers and staff know who the high-risk patients are, they can take steps to ensure that any extra care the patient may need is given, which will help prevent readmission.

2. Communicating effectively among providers and care teams. The hallmark of an excellent readmission reduction program is excellent communication, says Dr. Hildebrand. The healthcare team must communicate appropriately, clearly and in a timely manner with one another, he says.

One strategy that hospitals can implement to improve communication is multidisciplinary bedside rounding. This type of rounding requires all caregivers — physicians, nurses, specialists, case managers — to visit the patient at the same time and discuss the patient's care plan together, along with the patient.

The care team must also use appropriate and thorough documentation to relay information to each other and to outpatient providers who will take over the case once the patient leaves the hospital. Outpatient providers need to be given a detailed discharge summary so they are aware of any issues that could potentially result in a patient being readmitted. "There needs to be direct and concrete communication between providers to ensure no confusion," says Dr. Gundersen.

3. Educating patients. Involving patients and their families in the care process helps ensure patients have a clear understanding of their condition and treatment plan. This also ensures that patients can follow the post-discharge plan more effectively, says Dr. Gundersen. Once the patient leaves the hospital, the provider has no control over the patient's care. It is therefore essential that patients fully understand the discharge instructions.

"When it is not done well, it's the patient who suffers," says Dr. Hildebrand.

Patients may take the wrong medication, forget to go for follow-up appointments, experience symptoms they do not understand and then return to the hospital, he says.

One method hospital providers can use to make sure patients have understood instructions is the "teach-back" method, says Dr. Gundersen, which involves asking patients to repeat the instructions back to providers.

4. Following up post-discharge. According to Dr. Hildebrand, following up with patients after they leave is a proven method of reducing readmissions.

One way to do this is by implementing a patient callback system, says Daniel Virnich, MD, CMO of TeamHealth Hospital Medicine. Hospitals can follow-up with patients over the phone to see how they are doing, if they are following the discharge instructions and if they have any questions. "If the patient is exhibiting certain symptoms that indicate that they may have to be readmitted, the hospital can intervene and triage the patient to a physician who can help before it gets to a point where the patient may have to be readmitted," says Dr. Virnich.

5. Improving the medication reconciliation process. "The medication reconciliation process is essentially a review of all medications and dosages of medicine that a patient is taking," says Dr. Hildebrand. Hospital clinicians need to make sure patients are taking the necessary medications in the correct dosage while they are in the hospital. They also need to ensure patients know what medication they need to take after discharge and where to get it.

"This is often a source of confusion for patients," says Dr. Gundersen. "Errors get made during the medication reconciliation process."

According to Dr. Virnich, hospitals also need to communicate the patients' medication requirements to outpatient providers to reduce to the risk of errors.

With CMS penalties on the rise, cutting inappropriate readmission rates needs to be incorporated into every hospital's performance improvement strategy. Hospitals will have to hardwire the aforementioned steps into their work processes, and physicians and staff must work as a team to be successful in achieving this. "It's first necessary to sell the vision and engage the buy-in of all the key stakeholders," says Dr. Hildebrand. However, with the support of its staff, the willingness of its physicians and the cooperation of the patients, hospitals can reduce readmission rates and thereby prevent reimbursement cuts.